The present randomised clinical trial was aimed at comparing three minimally invasive restorative treatment approaches for managing dental caries in occlusal surfaces using a non-gamma-2 amalgam and a low-viscosity glass-ionomer as the restorative material. The treatment approaches tested in parallel groups were: conventional in a university setting, modified-conventional and ultraconservative (Atraumatic Restorative Treatment, ART) approaches in a field setting. A split-mouth design was used in which the two restorative materials were randomly placed in 430 matched contralateral pairs of permanent molar teeth. A total of 152 children from five primary schools were recruited and treated by a dental therapist. The restorations were evaluated after 6 years by 2 calibrated independent examiners. The 6-year successes for all occlusal amalgam and glass-ionomer restorations were 72.6 and 72.3%, respectively. There were no statistically significant differences observed between the successes for both amalgam and glass-ionomer restorations placed either by the ART (68.6%, with 95% CI = 61–76%) approach or by the conventional (74.5%, with 95% CI = 65–82%) and the modified-conventional (75.8%, with 95% CI = 67–83%) approaches after 6 years. There was also no statistically significant difference observed between the successes of occlusal ART restorations with glass-ionomer (67.1%, with 95% CI = 56–77%) and occlusal conventional restorations with amalgam (74%, with 95% CI = 61–85%) after 6 years. ‘Restoration fracture/marginal defects’ and ‘loss of material’ were the most common causes for failure. The former was more often recorded in amalgam restorations and the latter in glass-ionomer restorations. Secondary caries was observed for 2% of glass-ionomer and for 10% of amalgam restorations. This difference was statistically significant (p = 0.001). The ART approach using glass-ionomer performed equally well as conventional restorative approaches using electrically driven equipment and amalgam for treating dentinal lesions in occlusal surfaces after 6 years.

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The present study was aimed at comparing the effectiveness of three minimally invasive restorative treatment approaches for dentinal lesions in occlusal surfaces. The approaches tested comprised a conventional and a modified–conventional treatment and a modified Atraumatic Restorative Treatment (ART). The conventional approach was performed in a university dental clinic whilst the modified–conventional, employing portable equipment, and the modified ART, using hand instruments and a caries removal solution (Caridex^®), were carried out in the field. Using the split–mouth design, 430 matched contralateral pairs of occlusal cavities were restored with amalgam or glass–ionomers in permanent molars of 152 school children by one dental therapist. The restorations were assessed using a modified USPHS–Ryge criteria. After 2 years, the cumulative survival percentages for occlusal amalgam and glass–ionomer restorations were 92 and 96%, respectively. The survival of all restorations in the conventional, modified–conventional and the modified ART group was 96, 96 and 91%, respectively. The survival of occlusal amalgam and glass–ionomer restorations per treatment group was as follows: 94 and 99%, respectively (conventional group); 95 and 97%, respectively (modified–conventional group), and 89 and 93%, respectively (modified ART group). The differences in survival percentage between restorations with amalgam and glass–ionomer, and between the three restorative treatment approaches were not statistically significant. In countries facing scarcity in resources for dental care, ART seems a promising restorative approach to occlusal caries in posterior teeth. However, a longer clinical observation period is required to substantiate this initial conclusion.

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An increased involvement and support for ART from the Ministry of Health and professional organisations, and public education of ART is called for.